G. E. Martin1, C. Carroll2, Z. Plummer2, D. Millar1, T. Pritts1, A. T. Makley1, B. Joseph3, L. B. Ngwenya2, M. D. Goodman1 1University Of Cincinnati,Surgery,Cincinnati, OH, USA 2University Of Cincinnati,Neurosurgery,Cincinnati, OH, USA 3University Of Arizona,Surgery,Tucson, AZ, USA
Introduction: Patients with mild-to-moderate traumatic brain injury (TBI) are increasingly managed primarily by trauma/acute care surgeons. The Brain Injury Guidelines (BIG) were developed at an ACS-accredited level 1 trauma center to triage mild-to-moderate TBI patients and facilitate identification of patients warranting neurosurgical consultation. The BIG have not been validated at a level III trauma center. We hypothesized that BIG criteria can be safely adapted to an ACS-accredited level III trauma center to guide transfers to a higher echelon of care.
Methods: We reviewed the trauma registry at a level III trauma center to identify TBI patients who presented with an Abbreviated Injury Severity-Head score >0. Demographic data, injury details, and clinical outcomes were abstracted with primary outcome measures of worsening on repeat head CT, neurosurgical intervention, transfer to a level I trauma center, and in-hospital mortality. Patients were classified using the BIG criteria. After validating the BIG in our cohort, we reclassified patients using updated BIG criteria, including: mechanism of injury, anticoagulation or antiplatelet use into BIG-2 or BIG-3, and replacing the “neurologic exam” component with stratification by admission Glasgow Coma Scale (GCS) score.
Results: From July 2013 to June 2016, 332 TBI patients were identified: 114 BIG-1, 26 BIG-2, and 192 BIG-3. Patients requiring neurosurgical intervention (n=30) or who died (n=29) were BIG-3 with one exception. Patients with GCS <12 had worse outcomes than those with GCS ≥12, regardless of BIG classification. Anticoagulant or antiplatelet use was not associated with worsened outcomes in patients not meeting other BIG-3 criteria. The updated BIG resulted in more patients in BIG-1 (n=109) and BIG-2 (n=100) without negatively impacting outcomes.
Conclusion: The BIG can be applied in the level III trauma center setting. Updated BIG criteria can aid triage of mild-to-moderate TBI patients to a level I trauma center and may reduce secondary overtriage.
